Provider Demographics
NPI:1538539564
Name:MONTGOMERY, JARRETT
Entity type:Individual
Prefix:
First Name:JARRETT
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9100 WALKER RD
Mailing Address - Street 2:520
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2902
Mailing Address - Country:US
Mailing Address - Phone:318-237-5868
Mailing Address - Fax:
Practice Address - Street 1:3018 OLD MINDEN RD
Practice Address - Street 2:520
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-2476
Practice Address - Country:US
Practice Address - Phone:318-658-9927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health